Wiki Need to know if i have used the correct DX code

[lataashwini23@gmail.com]

For the following chart note i have used S43.402A, just need to know if t hat is correct

Chief Complaint: L shoulder pain History of Present Illness: 22 yo female presents c/o L shoulder pain s/p MVA on 12/11/2019. Pt was the restrained driver when she was hit on R upper side of car by merging car. Airbags did not deploy. Pt did not hit head or another part of body. Pt felt ok initially, then had some neck pain. Pt took Naproxen on 12/12/2019 for period cramps. Pt did not notice L shoulder pain until 3 days ago. Pt states the pain got worse yesterday and she has had difficulty moving her L shoulder. Pt took naproxen today which helped. Review of Systems: Cardiovascular: Denies Chest Pain General: Denies Fatigue Musculoskeletal: Admits Decreased Range of Motion and Joint Pain Neurological: Denies Numbness and Paresthesia Vital Signs: Temp 98 F - Oral, Pulse 61 b/m , Respiration 16 b/m, BP 112/72 mm/Hg - SittingSAO2 98% Taken on Dec 15, 2019 at 12:26 PM by CMA Armijo, Luis Allergies: NKDA Current Medications: Aleve 220 MG Oral Tablet: 1 Tablet(s) daily , For 1 Day(s) Physical Exam: Constitutional Appearance: No distress, Alert and oriented x 3 Neck Range of Motion: Supple Respiratory Respiratory Effort: No acessory muscle use no distress; Auscultation of Lungs: Normal breath sounds Cardiovascular Findings: Regular rate and rhythm, no murmurs/rubs or gallops, S1/S2 present Musculoskeletal L shoulder: mild ttp on upper trapezius. ROM reduced with abduction, pain with internal and external rotation Neurologic Gait and Station: Ambulatory Psychiatric Judgment and Insight: Appears appropriate; Mood and Affect: Affect appropriate Assessment And Plan: 22 yo female presents with L shoulder 2 days s/p MVA. Suspect muscle strain due to seatbelt. Pt will start with conservative tx of NSAIDs, heat, acupuncture/massage/chiro/PT. If no improvement or worsening sx, RTO in 2-4 days.

 

[mitchellde]

You do not code suspected conditions, so since it is documented as a suspected muscle strain, code only the left shoulder pain.